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Summary Plan Description - cardayassociates.com

Summary Plan Description ASBESTOS WORKERS LOCAL 24 MEDICAL FUND Effective March 1, 2012 Summary Plan Description This newly-revised booklet is intended to explain your medical, dental, vision, prescription, death and dismemberment benefits and loss-of-time (Accident and Sickness Benefits) in non-technical language. It is also intended to give you an understanding of how the Fund is operated for your benefit. As indicated in the descriptions of benefits below, some benefits under the Fund are provided pursuant to Contracts of Insurance. With respect to those benefits, those Contracts constitute the Plan Document, and, those benefits (including any applicable claims and other procedures), are provided pursuant to the terms of those Contracts of Insurance, which constitute the Plan Document. The remaining benefits provided by the Fund are provided pursuant to this Summary Plan Description which, with respect to those benefits, serves as the Plan Document.

Summary Plan Description This newly-revised booklet is intended to explain your medical, dental, vision, prescription, death and dismemberment benefits and loss-of …

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Transcription of Summary Plan Description - cardayassociates.com

1 Summary Plan Description ASBESTOS WORKERS LOCAL 24 MEDICAL FUND Effective March 1, 2012 Summary Plan Description This newly-revised booklet is intended to explain your medical, dental, vision, prescription, death and dismemberment benefits and loss-of-time (Accident and Sickness Benefits) in non-technical language. It is also intended to give you an understanding of how the Fund is operated for your benefit. As indicated in the descriptions of benefits below, some benefits under the Fund are provided pursuant to Contracts of Insurance. With respect to those benefits, those Contracts constitute the Plan Document, and, those benefits (including any applicable claims and other procedures), are provided pursuant to the terms of those Contracts of Insurance, which constitute the Plan Document. The remaining benefits provided by the Fund are provided pursuant to this Summary Plan Description which, with respect to those benefits, serves as the Plan Document.

2 Board of Trustees The Plan Administrator is the Board of Trustees of the Asbestos Workers Local 24 Medical Fund: Union Trustees Employer Trustees Lino Cressotti, Chairman R. Steve Shegogue, Secretary Brian Cavey Alan "Skip" Stortzum Robert McCourt Rick Schmid The Board may be contacted at: Asbestos Workers Local 24 Medical Fund 7130 Columbia Gateway Dr. Suite A Columbia, MD 21046 ( 410) 872-9500 Day-to-day administration is provided by: Carday Associates, Inc. 7130 Columbia Gateway Dr. Suite A Columbia, MD 21046 ( 410) 872-9500 Attorney Mooney, Green, Saindon, Murphy & Welch, 1920 L Street, , Suite 400 Washington, DC 20036 Auditor Daniel A. Winters & Company Certified Public Accountants 6 Dickinson Drive, Suite 205 Chadds Ford, PA 19317-9669 Life Insurance and AD&D AIG Benefit Solutions Tampa Solutions Center 3501 Frontage Road Tampa, Florida 33607-1704 Policy # 492F94 PPO CareFirst BlueCross BlueShield Box 10104 Fairfax, VA 22038-8004 MD, DC or Northern Va: 1-800-235-5160 All Other Areas: 1-888-444-8115 Prescription Drug Provider CVS/Caremark Address for Mail Order Pharmacy: Caremark Box 94467 Palatine, IL 60094-4467 Address to Submit Paper Claims: CVS/Caremark Claims Department Box 52196 Phoenix, AZ 85072-2196 (866) 282-8503 Customer Care Utilization Review/Large Case Management American Health Holding, Inc.

3 100 West Old Wilson Bridge Road Third Floor Worthington, OH 43085 800-641-5566 i TABLE OF CONTENTS INTRODUCTION .. 1 Administration and History .. 1 Financing Your Benefits .. 2 Change of Eligibility Rules And Benefits .. 3 General Information .. 3 ELIBILITY .. 4 Who Can Become Eligible .. 4 Employees .. 4 Employees of Employers Owned By Relatives .. 5 Employees with an Ownership Interest in an Employer .. 6 Non-Bargaining Unit Employees of Incorporated Employers .. 6 Dependents .. 7 Disabled Employees, Retirees, and Surviving Spouses .. 8 BENEFITS FOR WORKING EMPLOYEES .. 9 COMPREHENSIVE PLAN SCHEDULE OF BENEFITS .. 9 EMPLOYEES IN HAZMAT WORKERS PLAN .. 11 How You Become Eligible for Benefits .. 12 Initial Eligibility .. 13 Continuing Your Eligibility .. 15 How You Can Lose Eligibility .. 15 Lost Your Eligibility? How To Get It Back .. 16 Veterans Rights .. 16 What Happens if You Don't Have Enough Hours ..Self-Payments.

4 16 Alternative Self-Payment Rules (COBRA) .. 19 Continuing Your Eligibility While Totally Disabled .. 22 CONTINUING ELIGIBILITY FOR YOUR DEPENDENTS AFTER YOUR DEATH .. 23 Continuing Eligibility While Working Out of Area .. Reciprocity .. 24 Continuing Your Eligibility During Family and Medical Leave .. 24 EMPLOYEES IN NEWLY ORGANIZED GROUPS AND NEWLY INDENTURED APPRENTICES .. 26 Schedule of Benefits .. 26 Which Employees Qualify for These Special Rules? .. 27 To What Period Do These Special Rules Apply? .. 27 ii Initial Eligibility .. 28 Preexisting Condition Exclusion .. 28 Continuing Your Eligibility .. 29 How You Can Lose Eligibility .. 29 Lost Your Eligibility? How To Get It Back .. 29 CONTINUING YOUR ELIGIBILITY WHILE YOUR RETIRED .. 30 Death Benefits .. 30 Medical Benefits .. 30 Plan of Health Benefits For Retirees .. 32 People Covered By Retiree Benefits .. 33 Payment for Retiree Benefits .. 34 Termination of Retiree Benefits.

5 34 Suspension of Benefits to Participate in a Medicare HMO .. 35 Suspension of Benefits When Retiree Has Other Coverage .. 35 Continuing Eligibility for Your Dependents After Your Death .. 35 Eligibility for Reduced Retiree Premiums .. 36 PREFERRED PROVIDER ORGANIZATION (PPO) .. 38 VOLUNTARY PRECERTIFICATION/UTILIZATION REVIEW .. 39 WEEKLY ACCIDENT AND SICKNESS BENEFITS FOR ACTIVE ELIGIBLE EMPLOYEES - OFF THE JOB ILLNESS OR INJURY .. 41 Amount of 42 Period of Coverage .. 42 WORKERS' COMPENSATION SUPPLEMENT .. 42 ANNUAL PHYSICAL .. 43 COMPREHENSIVE MEDICAL BENEFITS .. 43 Who Is 43 Amount of Coverage .. 43 Usual, Customary and Reasonable (UCR) .. 43 Deductible .. 44 Amount .. 45 Annual Plan .. 45 Lifetime Plan .. 45 What Is Covered .. 45 Hospital Charges .. 45 Maternity and Obstetrical Benefits .. 47 Women s Health and Cancer Rights Act of 1998 .. 48 Outpatient and Out-of-Hospital Care, Including Emergency First Aid.

6 48 iii Surgical Benefits .. 49 Mental Health and Alchol and Chemical Dependency .. 49 Medical Benefits for Dental Treatment .. 50 Hospice Care .. 50 Benefits Paid After Employee's or Dependent's Death .. 50 Items Not Covered By the Medical Plan .. 51 Limited Benefits .. 53 PRESCRIPTION DRUG BENEFIT .. 55 Co-Payments .. 55 Participating Pharmacies .. 56 Generic and Brand Name Drugs .. 56 Formulary Drugs .. 56 Covered Prescription Drug Expenses .. 56 Maintenance Drug Program .. 57 Limitations and Exclusions .. 57 DENTAL BENEFITS .. 58 Who Is 58 What Is Covered .. 58 Covered Items .. 59 Items Not Covered by the Plan .. 61 VISION BENEFITS .. 62 Benefit Schedule of Allowances .. 62 Benefits Covered .. 63 Exclusions .. 63 HEARING AID BENEFIT .. 64 LIFE INSURANCE AND ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS .. 64 Who is Covered .. 64 Amount of Death Benefits .. 64 Dismemberment Benefits .. 65 Beneficiary .. 65 Exclusions.

7 66 Total and Permanent Disability .. 66 GENERAL EXCLUSIONS .. 67 COORDINATION OF BENEFITS .. 68 Coordination with HMO .. 69 Coordination with PPOs .. 69 iv Coordination When Husband and Wife Are Covered by This Fund .. 69 Coordination With Medicare .. 69 Eligible Employees and Their Spouses .. 69 Retirees and Their Spouses .. 70 BENEFITS PAID WHERE A THIRD PARTY MAY BE LIABLE .. 70 Right of Recovery .. 72 CLAIMS AND APPEALS .. 73 PPO Claims .. 74 OTHER INFORMATION .. 82 Facts You Should Know About Your Rights .. 82 PRIVACY PRACTICES .. 84 More Important Facts .. 90 1 INTRODUCTION The Asbestos Workers Local 24 Medical Fund ( Fund ) offers you and your family protection when there is a need for: Medical Care (including hospitalization and physician's care) Prescription Benefits Dental Care; and Vision Care. The Fund also provides benefits to you or your beneficiaries in the event of your: Death; or Loss-of-time because of a short-term disability.

8 Administration and History The Fund became effective December 1, 2004, when the Heat and Frost Insulators and Allied Workers Local 24 ( Local 24") and its signatory Employers separated from the National Asbestos Workers Medical Fund ( National Fund ). The Fund is jointly administered by a Board of Trustees. Half of the Trustees are designated by the Employers and half are designated by Local 24, as required by the Labor Management Relations Act of 1947 (known as the LMRA or Taft-Hartley Act ). The Trustees meet at least quarterly, as necessary to hear appeals and oversee the operation of the Fund. The Board of Trustees, in turn, employs the services of a professional benefits administration firm (also known as an administrative agent ) to handle the day-to-day operation of the Plan. The administrative agent is Carday Associates, Inc.

9 Healthcare Reform The Trustees believe this plan is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. 2 Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at the address and phone number shown above.

10 You may also contact the Employee Benefits Security Administration, Department of Labor at 1-866-444-3272 or This website has a table summarizing which protections do and do not apply to grandfathered health plans. Financing Your Benefits The Fund is maintained pursuant to collective bargaining agreements between the Employers and Local 24. These agreements require that Employers contribute for every hour you work. This is the primary source of income to the Fund contributions required for hours worked by active Employees. Each Employer who contributes to the Fund submits a report on forms provided monthly by the Fund. Participants and beneficiaries may receive from the Board of Trustees, upon written request, information as to whether a particular employer participates in the Plan and, if the employer does participate, the employer's address.


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